Changes over time of fruit, vegetable and sweets consumption among European adolescents and associations with sociodemographic characteristics: an HBSC study.

BACKGROUND: European adolescents do not eat enough fruits and vegetables and have a high sweets consumption. This study aims to analyse the changes in time of dietary behaviours related to sociodemographic characteristics, among European adolescents. METHODS: Health Behaviour in School Age Children data (2013/14 to 2017/18), of European adolescents, aged 11- to15-year-old, were used. Family Affluence Scale identified socioeconomic status (SES). Changes in time of dietary behaviours and associations with sociodemographic characteristics were estimated by binary and multilevel logistic regression. RESULTS: 182 719 adolescents were included, and 10/36 European countries showed a significant increase in daily fruit and vegetable consumption and 12/36 countries a significant decrease in sweets consumption over 4 years. The multilevel analysis showed that 13- and 15-year-old adolescents consumed fewer daily fruits and vegetables (P < 0.001) and more daily sweets (P < 0.001) than 11-year-old adolescents. Also, 15-year-old adolescents' sweets consumption change over time was less favourable (P = 0.006). Girls consumed more daily fruits, vegetables and sweets than boys (P < 0.001).Low SES adolescents consumed fewer daily fruits and vegetables than medium/high SES adolescents. Additionally, the low SES adolescents' vegetable consumption change over time was less favourable (P < 0.001). CONCLUSIONS: Dietary behaviour policy recommendations should be adapted for the sex, age and SES of the population.

Evaluation of practice nurses' management of paediatric psychosocial problems in general practice.

BACKGROUND: Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs. METHODS: We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis. RESULTS: Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive. CONCLUSIONS: YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care.

The association between perceived social support and parenting self-efficacy among parents of children aged 0-8 years.

Strengthening social support has been recognized as a potentially effective strategy to enhance parenting self-efficacy, but empirical evidence is limited. This study examined the association between perceived social support and parenting self-efficacy.Data of 647 parents of children aged 0-8 years, gathered in the CIKEO cohort study in the Netherlands, were analysed. Data were collected between October 2017 and December 2019. Multivariable linear regression models were used to examine the association between social support and parenting self-efficacy. The mean age of the participants was 33.8 years (SD = 4.9); 94.9% mothers. At the start of the study, 15.1% parents perceived low to moderate social support. Parents who experienced lower levels of social support at the start of the study reported lower parenting self-efficacy at follow-up (ß: 0.13; 95% CI: 0.05, 0.21), independent of potential socio-demographic confounders. Experiencing an increase in perceived social support during the study period was associated with an increase in parenting self-efficacy (ß: 0.15; 95% CI: 0.10, 0.21). Our findings indicate perceived social support is associated with parenting self-efficacy among parents of children aged 0-8 years. Future longitudinal studies need to confirm our findings and may examine which social support interventions are effective in strengthening parenting self-efficacy.

Associations between organised leisure-time activities and mental health problems in children.

Previous studies conducted mainly among adolescents have found associations between participation in sport organised leisure-time activities (OLTAs) and mental health problems (MHP). Fewer research studies have been performed to primary school-aged children and to organised non-sport OLTAs. Therefore, the objective is to examine whether there is an association between participation in sport and non-sport OLTAs and a high risk of MHP in 4- to 12-year-olds. Data were used on 5010 children from a cross-sectional population-based survey conducted between May and July 2018 in Rotterdam, the Netherlands. Associations between sport OLTAs, non-sport OLTAs and breadth of OLTAs and a high risk of MHP were explored using logistic regression models adjusting for sociodemographic characteristics, stressful life events and physical activity. Of all children, 58% participated in sport OLTAs and 22% in non-sport OLTAs. The proportion of children with high risk of MHP among participants in sport OLTAs is smaller than among non-participants (OR 0.66, 95% CI: 0.53, 0.81). The proportion of children with high risk of MHP among participants in non-sport OLTAs is smaller than among non-participants (OR 0.69, 95% CI: 0.53, 0.91). The proportion of children with a high risk of MHP among participants in 1 category of OLTAs (OR 0.61, 95% CI: 0.49, 0.76) and in 2-5 categories of OLTAs (OR 0.48, 95% CI: 0.32, 0.71) is smaller than among non-participants.  Conclusion: The proportion of children with high risk of MHP among participants in OLTAs is smaller than among non-participants. What is Known: • Around 10--20% of children and adolescents experiences mental health problems. • Sport organised leisure-time activities have been found to be associated with a lower risk of mental health problems in adolescents. What is New: • The proportion of children with a high risk of mental health problems in participants in organised leisure-time activities is smaller than among non-participants. • The proportion of children with a high risk of mental health problems in participants with a higher breadth of organised leisure-time activities is smaller compared to non-participants.

Clustering of characteristics associated with unplanned pregnancies: the generation R study.

BACKGROUND: Unplanned or unintended pregnancies form a major public health concern because they are associated with unfavorable birth outcomes as well as social adversity, stress and depression among parents-to-be. Several risk factors for unplanned pregnancies in women have previously been identified, but studies usually take a unidimensional approach by focusing on only one or few factors, disregarding the possibility that predictors might cluster. Furthermore, data on predictors in men are largely overlooked. The purpose of this study is to determine predictors of unplanned versus planned pregnancy, to determine predictors of ambivalent feelings regarding pregnancy, and to investigate how characteristics of men and women with an unplanned pregnancy cluster together. METHODS: This study was embedded in Generation R, a multiethnic population-based prospective cohort from fetal life onwards. Pregnancy intention was reported by 7702 women and 5367 partners. Information on demographic, mental, physical, social, and sexual characteristics was obtained. Logistic regression, multinomial regression and cluster analyses were performed to determine characteristics that were associated with an unplanned pregnancy, with ambivalent feelings regarding the unplanned pregnancy and the co-occurrence of characteristics in women and men with unplanned pregnancy. RESULTS: Twenty nine percent of the pregnancies were unplanned. Logistic regression analyses showed that 42 of 44 studied predictors were significantly associated with unplanned pregnancy. The most important predictors were young age, migration background, lower educational level, lower household income, financial difficulties, being single, lower cognitive ability, drug use prior to pregnancy, having multiple sexual partners in the year prior to the pregnancy, younger age of first sexual contact and a history of abortion. Multinomial regression analyses showed that a Turkish or Moroccan background, Islamic religion, little financial opportunities, being married, having ≥3 children, high educational level, more mental health and social problems and older age of first sexual contact were associated with prolonged ambivalent feelings regarding pregnancy. Different combinations of characteristics were observed in the four clusters of women and men with unplanned pregnancy. CONCLUSIONS: Many predictors are related with unplanned pregnancies, ambivalent feelings toward the pregnancy, and we identified very heterogeneous groups of women and men with unplanned pregnancies. This calls for heterogeneous measures to prevent unplanned pregnancies.

Parental, child and socio-contextual factors associated with parenting self-efficacy among parents of children aged 0-7 years old: the CIKEO study.

BACKGROUND: A high parenting self-efficacy (PSE) has been associated with positive parenting and positive child development. However, there is limited and inconsistent information on factors associated with PSE. OBJECTIVE: To investigate factors associated with PSE in parents of children aged 0-7 years old, and to explore whether the associations were different between mothers and fathers. METHODS: We performed a cross-sectional analysis of the baseline data from a prospective cohort study: the CIKEO study. A total of 1012 parents (mean age = 33.8, SD = 5.0) completed self-reported measure of PSE and 18 potential factors associated with PSE. RESULTS: Multivariable models revealed that lower parenting stress, fewer child behavior problems, better eating behavior, better parental and child general health, a smaller number of children living in the household, higher perceived level of social support and having a migration background were associated with higher levels of PSE (p < 0.05). The association between family functioning and PSE differed between mothers and fathers (p for interaction = 0.003): with beta and 95% confidence interval being: 1.29 (- 2.05, 0.87), and 0.23 (- 0.46, 3.29), respectively. CONCLUSIONS: A range of parental, child and social-contextual factors in relation to PSE were identified. The patterns of associations for most of the factors were similar among mothers and fathers. However, the association between family functioning and PSE might differ for mothers and fathers. Our findings are relevant for tailoring and implementing successful interventions and effective policy making in child care. TRIAL REGISTRATION: Netherlands National Trial Register number NL7342. Date of registration: 05-November-2018, retrospectively registered.

Identifying patterns of lifestyle behaviours among children of 3 years old.

BACKGROUND: To identify the patterns of lifestyle behaviours in children aged 3 years, to investigate the parental and child characteristics associated with the lifestyle patterns, and to examine whether the identified lifestyle patterns are associated with child BMI and weight status. METHODS: Cross-sectional data of 2090 children 3 years old participating in the Dutch BeeBOFT study were used. Child dietary intakes, screen times and physical activity were assessed by parental questionnaire, and child weight and height were measured by trained professionals according to a standardized protocol. Latent class analysis was applied to identify patterns of lifestyle behaviours among children. RESULTS: Three subgroups of children with distinct patterns of lifestyle behaviours were identified: the 'unhealthy lifestyle' pattern (36%), the 'low snacking and low screen time' pattern (48%) and the 'active, high fruit and vegetable, high snacking and high screen time' pattern (16%). Children with low maternal educational level, those raised with permissive parenting style (compared those with authoritative parents), and boys were more likely be allocated to the 'unhealthy lifestyle' pattern and the 'active, high fruit and vegetable, high snacking and high screen time' pattern (P < 0.05). No association was found between the identified lifestyle patterns and child BMI z-score at age 3 years. CONCLUSIONS: Three different lifestyle patterns were observed among children aged 3 years. Low maternal educational level, permissive parenting style and male gender of the child were associated with having unhealthy lifestyle patterns for the child.

Different Perspectives on Predictability and Preventability of Surgical Readmissions.

BACKGROUND: Although unscheduled readmissions are increasingly being used as a quality indicator, only few readmission studies have focused on surgical patient populations. METHODS: An observational study "CURIOS@" was performed at three centers in the Netherlands. Readmitted patients and treating doctors were surveyed to assess the discharge process during index admission and their opinion on predictability and preventability of the readmission. Risk factors associated with predictability and preventability as judged by patients and their doctor were identified. Cohen's kappa was calculated to measure pairwise agreement of considering readmission as predictable/preventable. PRISMA root cause categories were used to qualify the reasons for readmission. RESULTS: In 237 unscheduled surgical readmissions, more patients assessed their readmissions to be likely preventable compared with their treating doctors (28.7% versus 6.8%; kappa, 0.071). This was also reflected in poor consensus about risk factors and root causes of these readmissions. When patients reported that they did not feel ready for discharge or requested their doctor to allow them to stay longer at discharge during index admission, they deemed their readmission more likely predictable and preventable. Doctors focused on measurable factors such as the clinical frailty scale and biomarkers during discharge process. Health-care worker failures were strongly associated with preventable readmissions. CONCLUSIONS: There is no consensus between readmitted patients and treating doctors about predictability and preventability of readmissions, nor about associated risk factors and root causes. Patients should be more effectively involved in their discharge process, and the relevance of optimal communication between them should be emphasized to create a safe and efficient discharge process.

Associations between family and home-related factors and child's snack consumption in a multi-ethnic population.

BACKGROUND: Energy-dense snacks are considered unhealthy due to their high concentrations of fat and sugar and low concentrations of micronutrients. The present study aimed to evaluate associations between family and home-related factors and children's snack consumption. We explored associations within subgroups based on ethnic background of the child. METHODS: Cross-sectional data of 644 primary school children (mean age: 9.4 years, 53% girls) from the population-based 'Water Campaign' study conducted in the Netherlands were used. Logistic regression analyses were used to evaluate the associations between family and home-related factors and child's snack intake. RESULTS: Of the children, 28.7% consumed more than one snack per day. Children of parents who expressed more restrictive parenting practices towards the child's snack consumption (odds ratio (OR) = 2.5, P < 0.001), and who modelled snack eating less often (OR = 2.2, P < 0.001) had lower snack intake. Restrictive parenting practices and parental modelling of healthy snacking were significant for children with a Dutch or Moroccan/Turkish ethnic background, but not for children with a Surinamese/Antillean ethnic background. CONCLUSIONS: We observed that parenting practices and parental modelling were independently associated with the child's snack intake. Also, the relationships between these factors and the child's snack consumption differed for children with distinct ethnic backgrounds.

Evaluation of the promising neighbourhoods community program to reduce health inequalities in youth: a protocol of a mixed-methods study.

BACKGROUND: Reducing socioeconomic health inequalities among youth is a major challenge for governments around the world and reports on successful attempts are scarce. Socioecological and integral approaches with collaborative partnerships and community engagement are recommended but knowledge about the effectiveness and effective and ineffective elements is limited. The Promising Neighbourhoods program employs such an approach aiming to reduce socioeconomic inequalities in health, safety and talent development in youth. We will evaluate the process-implementation, and effectiveness of the Promising Neighbourhoods program. METHODS/DESIGN: Core elements of Promising Neighbourhoods are a collaborative community programming approach with stakeholders, data-based priority setting, knowledge-, and theory-based policies and evidence-based interventions. Community stakeholders and key-leaders from the neighbourhoods are engaged in the program. For this evaluation study the program will be implemented in three intervention neighbourhoods. These neighbourhoods will be compared to three control neighbourhoods at baseline in 2018/2019 and at follow-up in 2020/2021 after full implementation of the Promising Neighbourhoods program. Intervention neighbourhoods receive a tailored intervention-package including evidence-based interventions and additional measures by community stakeholders. In control neighbourhoods, no special planning will take place thus interventions are offered as usual. A mixed-methods approach following the stages of the logic model from program is applied for this evaluation. Questionnaires, focus groups, and registration data will be collected among community stakeholders, key-leaders, and youth to evaluate the process-implementation of the program. Indicators of intermediate and ultimate outcomes will be studied among N = 818 children and N = 818 youngsters using difference-in-difference regression analysis to evaluate the effectiveness of the Promising Neighbourhoods program. DISCUSSION: Hypotheses are that a collaborative community approach with stakeholders leads to clear priority-setting and better tailored interventions of better quality. We further hypothesise a decline in socioeconomic inequalities in intermediate and ultimate outcomes for health, safety and talent development in the intervention neighbourhoods in comparison to control neighbourhoods. The results add knowledge about effective and ineffective elements of collaborative community programming approaches to reduce health inequalities in youth and thus are relevant for local and national public health authorities. TRIAL REGISTRATION: Netherlands National Trial Register number NL7279 . Date of registration: 26-Sept-2018.

Evaluation of effectiveness of (elements of) parenting support in daily practice of preventive youth health care; design of a naturalistic effect evaluation in 'CIKEO' (consortium integration knowledge promotion effectiveness of parenting interventions).

BACKGROUND: The number of interventions to support parents is growing. The level of evidence regarding these intervention varies. In this paper we describe a study that aims to assess the effectiveness of specific 'elements' within such parenting interventions for families with children up to 7 years. A naturalistic effect evaluation will be applied. Study questions are: 1. What is the exposure of parents to (elements of) parenting interventions in the daily practice of preventive youth health care? 2. What are the associations between the exposure to (elements of) parenting interventions and outcomes in parents/children related to parenting and child development? METHODS/DESIGN: Thousand parents/caregivers are recruited by preventive youth health care providers in the Netherlands. Measurements will be performed after inclusion and after 12-months follow up. Data regarding child/parent/caregiver characteristics, use of (parenting) interventions and care, and outcomes with regard to parenting skills, family functioning and child development will be collected. Outcomes will be compared between parents/children exposed and non-exposed to the (elements of) parenting interventions (adjusting for confounders). DISCUSSION: We hypothesize that parents/caregivers with exposure to (elements of) parenting interventions show (relatively more) improvements in parenting outcomes. Results will support intervention selection/development, and support communities/professionals to select appropriate intervention-elements. TRIAL REGISTRATION: Netherlands National Trial Register number NL7342 . Date of registration: 05-November-2018, retrospectively registered.

Effectiveness of interventions to improve lifestyle behaviors among socially disadvantaged children in Europe.

Background: Unhealthy lifestyle behaviors and childhood overweight are more common among children from families with a low socioeconomic position and ethnic minority children (referred to as social disadvantaged children). : This systematic review evaluates the effectiveness of interventions aimed to improve lifestyle behaviours and/or prevent overweight among socially disadvantaged children in Europe. : Six major databases were searched for studies reporting intervention effects on adiposity measures, sedentary behaviours, physical activity behaviours or dietary behaviours. Studies were included when the study sample consisted of at least 50% socially disadvantaged children or when results were presented for subgroups of socially disadvantaged children separately. Methodological quality assessment was based on Cochrane criteria. In total, 11 studies reporting on eight interventions (one among infants 0-2 years, one among preschoolers 2-6 years, six among school-aged children 6-12 years) were identified. Of these eight interventions, five interventions primarily aimed to improve at least one adiposity measure and three primarily aimed to improve a specific lifestyle behaviour. In general, modest positive effects were found but interventions were limited by a short follow-up duration. Despite an urgent need for effective interventions to improve lifestyle behaviours and prevent overweight among socially disadvantaged children, research on the effectiveness of interventions in Europe is still scarce. Those interventions that have been evaluated show modest effects on lifestyle behaviours and adiposity measures, but long-term follow-up is needed to establish whether these effects are sustained over a longer period of time.

PROP taster status, food preferences and consumption of high-calorie snacks and sweet beverages among 6-year-old ethnically diverse children.

A healthy diet is important for optimal growth and development in children. Food preferences are a main determinant of children's intake. The aim of this study was to examine the associations of 6-n-propylthiouracil (PROP) taster status (taste sensitivity to PROP) with children's food preferences and consumption of high-calorie snacks and sweet beverages among ethnically diverse children. We analysed data from 5585 6-year-old children enrolled in the Generation R Study, a birth cohort study in Rotterdam, the Netherlands. PROP taster status was evaluated using a suprathreshold screening solution. Food preferences of the children were assessed by a two-stage protocol using photographs of eight food items (candy, chocolate, mayonnaise, whipped cream, soup, potato chips, carrot and bread), yielding both hedonic ratings (1-3) and rank order scores (1-8). Univariate and multivariable linear and logistic regression analyses were performed, using tasters as the reference group. Non-tasters had a slightly higher preference for carrots (ß: -0.07; 95% CI: -0.13, -0.02 and ß: -0.15; 95% CI: -0.27, -0.02 for hedonic ratings and rank order scores, respectively) and bread (hedonic ratings; ß: -0.06; 95% CI: -0.11, -0.01) compared with tasters. No differences were found in children's preference for sweet, fat or salty food items. Furthermore, there were no associations of PROP taster status with the consumption of high-calorie snacks ≥ 2 times/day (aOR: 1.06; 95% CI: 0.91,1.24) or sweet beverages ≥ 3 glasses/day (aOR: 1.06; 95% CI: 0.92,1.23). Other factors relating to the family food environment may be more important for young children's food preferences and consumption of high-calorie snacks and sweet beverages than their innate taste sensitivity.

Meal-Skipping Behaviors and Body Fat in 6-Year-Old Children.

OBJECTIVE: To assess the prospective associations of breakfast, lunch, and dinner skipping at age 4 years with body fat (ie, percent fat mass, body mass index [BMI], and weight status) at age 6 years. STUDY DESIGN: Data were analyzed from 5913 children participating in the Generation R Study, a population-based prospective cohort study in Rotterdam, The Netherlands. Meal-skipping behaviors were assessed through parent-report questionnaires. Children's weight and height were objectively measured and converted to BMI SDSs. Weight status (ie, overweight or normal weight) was defined according to age- and sex-specific cutoff points. At age 6 years, percent fat mass was assessed by dual-energy X-ray absorptiometry. Linear and logistic regression analyses were performed, adjusting for covariates and BMI at age 4 years. RESULTS: Breakfast skipping at age 4 years was associated with a higher percent fat mass at age 6 years (ß = 1.38; 95% CI, 0.36-2.40). No associations were found with BMI or weight status. Furthermore, no associations were found between lunch and dinner skipping at age 4 years and body fat at age 6 years. CONCLUSION: Breakfast skipping at age 4 years is associated with a higher percent fat mass at age 6 years. Further prospective studies, including intervention studies, are warranted to extend the evidence base on the directionality and causality of this association.

Effects of an intervention aimed at reducing the intake of sugar-sweetened beverages in primary school children: a controlled trial.

BACKGROUND: Since sugar-sweetened beverages (SSB) may contribute to the development of overweight in children, effective interventions to reduce their consumption are needed. Here we evaluated the effect of a combined school- and community-based intervention aimed at reducing children's SSB consumption by promoting the intake of water. Favourable intervention effects on children's SSB consumption were hypothesized. METHODS: In 2011-2012, a controlled trial was conducted among four primary schools, comprising 1288 children aged 6-12 years who lived in multi-ethnic, socially deprived neighbourhoods in Rotterdam, the Netherlands. Intervention schools adopted the 'water campaign', an intervention developed using social marketing. Control schools continued with their regular health promotion programme. Primary outcome was children's SSB consumption, measured using parent and child questionnaires and through observations at school, both at baseline and after one year of intervention. RESULTS: Significant positive intervention effects were found for average SSB consumption (B -0.19 litres, 95% CI -0.28;-0.10; parent report), average SSB servings (B -0.54 servings, 95% CI -0.82;-0.26; parent report) and bringing SSB to school (OR 0.51, 95% CI 0.36;0.72; observation report). CONCLUSIONS: This study supports the effectiveness of the water campaign intervention in reducing children's SSB consumption. Further studies are needed to replicate our findings. TRIAL REGISTRATION: Current Controlled Trials: NTR3400.

Sedentary behaviors, physical activity behaviors, and body fat in 6-year-old children: the generation R study.

BACKGROUND: Childhood overweight and obesity is a major public health concern. Knowledge on modifiable risk factors is needed to design effective intervention programs. This study aimed to assess associations of children's sedentary behaviors (television viewing and computer game use) and physical activity behaviors (sports participation, outdoor play, and active transport to/from school) with three indicators of body fat, i.e., percent fat mass, body mass index (BMI) standard deviation scores, and weight status (normal weight, overweight). METHODS: Cross-sectional data from 5913 6-year-old ethnically diverse children were analyzed. Children's weight and height were objectively measured and converted to BMI. Weight status was defined according to age- and sex-specific cut-off points of the International Obesity Task Force. BMI standard deviation scores were created, based on Dutch reference growth curves. Fat mass was measured my dual-energy X-ray absorptiometry (DXA). Sedentary and physical activity behaviors were assessed by parent-reported questionnaires. Series of logistic and linear regression analyses were performed, controlling for confounders (i.e., socio-demographic factors, family lifestyle factors, and other sedentary behaviors and physical activity behaviors). RESULTS: Sports participation was inversely associated with fat mass (p < 0.001), even after adjustment for socio-demographic factors, family lifestyle factors, and other sedentary behaviors and physical activity behaviors. No other independent associations were observed. CONCLUSIONS: The results of this study indicate that sports participation is inversely associated with percent body fat among ethnically diverse 6-year-old children. More research in varied populations including objective measurements and longitudinal designs are needed to confirm these current results.

Social inequalities in young children's sports participation and outdoor play.

BACKGROUND: Research on social inequalities in sports participation and unstructured physical activity among young children is scarce. This study aimed to assess the associations of family socioeconomic position (SEP) and ethnic background with children's sports participation and outdoor play. METHODS: We analyzed data from 4726 ethnically diverse 6-year-old children participating in the Generation R Study. Variables were assessed by parent-reported questionnaires when the child was 6 years old. Low level of outdoor play was defined as outdoor play <1 hour per day. Series of multiple logistic regression analyses were performed to assess associations of family SEP and ethnic background with children's sports participation and outdoor play. RESULTS: Socioeconomic inequalities in children's sports participation were found when using maternal educational level (p < 0.05), paternal educational level (p < 0.05), maternal employment status (p < 0.05), and household income (p < 0.05) as family SEP indicator (less sports participation among low SEP children). Socioeconomic inequalities in children's outdoor play were found when using household income only (p < 0.05) (more often outdoor play <1 hour per day among children from low income household). All ethnic minority children were significantly more likely to not to participate in sports and play outdoor <1 hour per day compared with native Dutch children. Adjustment for family SEP attenuated associations considerably, especially with respect to sports participation. CONCLUSION: Low SEP children and ethnic minority children are more likely not to participate in sports and more likely to display low levels of outdoor play compared with high SEP children and native Dutch children, respectively. In order to design effective interventions, further research, including qualitative studies, is needed to explore more in detail the pathways relating family SEP and ethnic background to children's sports participation and outdoor play.

Television viewing through ages 2-5 years and bullying involvement in early elementary school.

BACKGROUND: High television exposure time at young age has been described as a potential risk factor for developing behavioral problems. However, less is known about the effects of preschool television on subsequent bullying involvement. We examined the association between television viewing time through ages 2-5 and bullying involvement in the first grades of elementary school. We hypothesized that high television exposure increases the risk of bullying involvement. METHOD: TV viewing time was assessed repeatedly in early childhood using parental report. To combine these repeated assessments we used latent class analysis. Four exposure classes were identified and labeled "low", "mid-low", "mid-high" and "high". Bullying involvement was assessed by teacher questionnaire (n=3423, mean age 6.8 years). Additionally, peer/self-report of bullying involvement was obtained using a peer nomination procedure (n=1176, mean age 7.6 years). We examined child risk of being a bully, victim or a bully-victim (compared to being uninvolved in bullying). RESULTS: High television exposure class was associated with elevated risks of bullying and victimization. Also, in both teacher- and child-reported data, children in the high television exposure class were more likely to be a bully-victim (OR=2.11, 95% CI: 1.42-3.13 and OR=3.68, 95% CI: 1.75-7.74 respectively). However, all univariate effect estimates attenuated and were no longer statistically significant once adjusted for maternal and child covariates. CONCLUSIONS: The association between television viewing time through ages 2-5 and bullying involvement in early elementary school is confounded by maternal and child socio-demographic characteristics.

Validation of the SDQ in a multi-ethnic population of young children.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is a valuable screening tool for identifying psychosocial problems. Its performance in a multi-ethnic society, common to many paediatric health care workers, has not been investigated. Because it is important that screening instruments are valid and reliable for all ethnic groups within one society, we examined differences in the SDQ's psychometric properties in a multi-ethnic society. METHODS: The SDQ parent (n = 8114) and teacher form (n = 9355) were completed as part of a preventive health check for children aged 5-6 years of Dutch and non-Dutch ethnic backgrounds. The Child Behaviour Checklist (CBCL)/Teacher Report Form (TRF) was administered to a subsample. RESULTS: Factor analysis of the parent-rated SDQ showed different rating patterns for two of the five subscales for non-Dutch children as compared with Dutch children. Cronbach's alpha for the total difficulties score varied by ethnic group (0.73-0.78 parent-rated SDQ, 0.80-0.83 teacher-rated SDQ), and coefficients were generally smaller for non-Dutch than for Dutch children (P < 0.05). Alpha coefficients for subscales varied between 0.31-0.85 for ethnic groups. Inter-rater correlations between parents and teachers for the total difficulties score varied between 0.20-0.41 between ethnic groups and were larger for Dutch than for non-Dutch children (P < 0.05). Concurrent validity was acceptable for most scales and most ethnic groups. CONCLUSION: The total difficulties score of the parent- and teacher-rated SDQ is valid and reliable for different ethnic groups within Dutch society. However, there are differences in reliability and validity of the subscales, which makes interpretation of the subscales difficult for certain ethnic groups.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour.

BACKGROUND: Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems. METHODS: Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008­2009 were linked to psychiatric case register data over the years 2010­2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems. RESULTS: During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01­2.46). CONCLUSIONS: Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.